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Safety and Buildings Division County <br /> `at 201 W.Washington Ave.,P.O.Box 7162 64e n C <br /> I *CO��,� Madison,WI 53707-7162 Sanitary Permit Number(lobe filled in by Co.) <br /> Department of Commerce (608)266-3151 _c� �P <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information I L , ;5-,*n 6 <br /> a 6 7 <br /> Property Owner's Name -Parcel# Lot# Block# <br /> /v1e7t7Le Ae/%er <53d - 14 5-0 300 <br /> Property Owner's Mailing Address Property Location <br /> 7574 wafer Sic SW ' <br /> City,State Zip Code Phone Number . Section 1� <br /> 0A n blA ry SV X30 7(S"- (�S-(o 3(i 9S_ crrcle o ) <br /> II.Type of Building(check all that apply) T y� N; R�(fS E or <br /> 4?�1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> 11Public/Commercial-Describe UseAm ! r'w S sr ° A t✓U <br /> ❑State Owned-Describe Use ❑City ❑Village®Township of S w r S f L1/, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System <br /> B• ❑ Permit Renewal El Permit Revision El Change of L1 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> rI�V.Type of POWTS System: Check all that apply) <br /> ey Non-Pressurized ht-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 31 o , y/6 7A c7 7,At,-- IS- .s— <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 6100 80 tea.w <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu tier's Signature MP/MPRS Number Business Phone Number <br /> �fc1c �i�o k,n s 7/S= P6G- 4is`-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> A 776 o f/w 3S Zde 6sttrr w—c— s-rf X93 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing gent Signature(No Stamps) <br /> Surcharge Fee) w ��'r <br /> ❑Owner Given Reason for Denial tU-(,L� c',(..� <br /> IX.Conditions of Approval/Reasons for Disapproval _ <br /> , r C 'J <br /> OCT t 3 2003_01 1NIPTT PAR I <br /> J'i <br /> Attach complete plans(to the County only) e s po 1/2 x 11 inches in sin <br /> ZO ING <br /> SBD-6398 (R. 01/03) <br />